Good afternoon and welcome to Hot Topics in Occupational Environmental Neurology and Neurotoxicology. We have some housekeeping. I am Dr. Jonathan Rutchick. I am both a neurologist and an occupational environmental medicine physician, board certified in both. We're going to be speaking about a lot of topics today, but first, the course, as we mentioned, is Hot Topics in Occupational Environmental Neurology and Neurotoxicology. I think it's 2-2-3, and away we go. We're going to be speaking about a lot of exciting things today. There's so much to talk about. I could talk about a few things, but I like to talk about a lot because there's so much to teach and learn. Hopefully, I can see these from this angle. My background is both neurology and occupational medicine. As a neurology fellow, I did an occupational environmental medicine residency, an MPH, and some EMG in Boston after initially being in New York City and working in Boston, Massachusetts with BU, School of Public Health, and the chairman of neurology, Robert Feldman. I then, 22 years ago, moved to San Francisco and have a private practice where I'm also associate clinical professor at UCSF. I teach medical students, nurses, and residents on various topics of neurology and preventive health. I'm available. I'm a clinical physician and do a lot of evaluations, but I do a lot of treatment. See a lot of patients with all the things that general occupational medicine physicians and providers see every day. That's what this is really about, this lecture. I have no disclosures. We're going to talk about upper extremity pain and weakness, COVID, post-COVID, post-concussion dizziness, seizure syncope, and post-concussion seizures, a little bit of traumatic encephalopathy, and then a mishmash of things relating to toxicology, neurology, trauma, tremor. How do you tell what it is? Cognitive impairment, PTSD, and imaging, and then the bottom line for all of this, which is the major take-home message, relates to preventive health and lifestyle medicine, which we'll get to. If you've heard me speak before, a lot of the same themes are at play. Number one, let's be really thorough historians. Let's examine and consider testing, and this can be important, but remember that it is sensitive but not specific. Testing is sensitive but not specific. Consider and respect functional medical conditions, which are becoming a very high prevalence in our clinics today, 30% easily, closer to 50% of functional medical conditions, and remember sleep, diet, mood, and exercise is vital to primary, secondary, tertiary prevention and care, and I really think that that should be included in the standard of care for all patients with all medical conditions, and it basically is not. We'll start, first of all, with a corrections officer who's left arm pain and weakness after having COVID vaccine in the right deltoid. Hmm, 10 days after vaccine, has weakness, pain at night. Three months later, I saw the patient, nagging pain. I was told that prednisone improved the condition, so what's going on? Is it neck, shoulder? Is it post-COVID? Is it not? Is it post-vaccine? Is it not? But voila, there is some scapular winging, there's some atrophy, there's good external rotation, and the sensor exam is vague, so is it real weakness? Is this just like brachial plexitis, brachial plexopathy, et cetera, but remember it's post-vaccine. We see here in this picture, we have some scapular winging. When you think about brachial plexopathy, plexopathy, neuropathy, cervical radiculopathy, these are the things you've got to consider. How do you tell? Really, your exam and your history is important. This person had this symptom occur in the middle of the night. Of course, EMG is important at some point, and can there be denervation? EMG really depends on who is doing the EMG, and what you know about EMG, and ask the questions you ask of the person who's performing this with a needle, because it could be blatantly normal or it could be abnormal, and really the more experience that provider who does EMGs has, the more likely you're going to get good information, and hopefully they're available to answer your questions. So the NCV was sensory was normal. When you have a sensory NCV that's normal, you still have got to consider radiculopathy, because if it's abnormal, well then, as those who know much about nerves, if it's abnormal, then the injury is distal to the DRG. So it is a peripheral nervous injury, but in this case it's not, so that's confusing. But then there's a neurogram at some point, and then there's this interesting hourglass construction on the neurogram was actually done. There's hemidiaphragmatic elevation, LFT elevation. This patient actually had a CSF protein because they went to the ER, and they got a neurologist at a university hospital. So this is maybe consistent with a brachial neuropathy, flexopathy. But the Parson's-Turner syndrome is an idiopathic condition, but it's been reported in people with vaccines or even COVID. We'll talk about that. It's immune-mediated, but trauma, malignancy, even nerve blocks can cause this kind of thing. Post-infection reported in 14 days-ish, usually the upper trunk. So will we have always scapular winging? No. The most common selection is upper trunk area, serratus anterior can be involved. But the real take-home message here is that two-thirds of these people are misdiagnosed, and they may not get seen by anybody who gets them anywhere in this process for six months. It's pretty significant. Forty-four days average latency to diagnosis when it really occurred. This is a brachial plexus view where you see in the upper areas. I'm not sure if I can... Do I have a pointer? I guess I do. I can do here. So serratus anterior, this is the radial nerve, deltoid and brachial... These are the upper trunks, so they may be involved in some cases. Another good shot, just helping those who like to learn a little more clear. So you see that this is the serratus anterior coming down here, long branch of the long thoracic nerve. So this is the predilection for this upper trunk of the brachial plexus in these kinds of issues. A great shot here of this hourglass on the neurogram, scapular winging. Also they can be, you know, a few folks know by the anterior interosseous nerve, that can really be related to the pinch. So when you're examining for carpal tunnel, you're asking people to pinch. If they cannot pinch, sure, it can be median, but it can also be the AIN. Interestingly enough, these idiopathic Parsonage-Turner neuropathy, brachial plexopathy, immune-mediated conditions are long thoracic nerves, but also can be the AIN. And you have a pinch sign. You can see that there is these hourglass constructions. But COVID and peripheral neuropathy, you ask, can it cause Gilean Barre? Can it cause motor neuropathy, myopathy? You know, there's a lot of literature. You see things, there are case studies, case reports. The latest is, I'm pointing here, is mostly post-ventilator weaning. Motor neuropathy and motor neuropathy more than sensory neuropathy, hmm, interesting. So repeat that. That's an interesting topic. Motor and myopathy more than sensory neuropathy. Perinatal tibial and ulnar predilection, these are some papers. So we move on to COVID and headache, because we all see COVID and headache, but this person was 45 and developed all kinds of unusual things, but including pulsatile tinnitus. So you've heard this probably in your clinic loads and loads of times. I have tinnitus. My ear's ringing. Is it pulsatile? Hmm. Well, the MRI surely showed some increased ICP. But before I could really think about acetylsalomide, the patient got better. But pseudotumor is really something that has been reported with COVID, and I saw one. So generally speaking, COVID and neurology, we're talking about headaches. And headaches can certainly be contraction headaches. We'll talk more lately. More migraine. Migraine, the term migraine, you know, we'll talk about unilateral, throbbing, worse with exercise. Repeating, worse with exercise. So do you exercise? Yes. I feel much better. Well, that maybe makes me think it's stress and anxiety related, not migrainess. But why do we want to think about migraine? Well, pharmaceutical companies wanted to say migraine because we can then use migraine medicines. Anyhow, long-term symptoms for COVID, a lot of anxiety, depression, but as many as 80%. Very high. We know all about that. Gabapentin is reported to be a little better than other preventive medications. Vaccine-associated headache, not specific. Again, we talked neuropathy, some few treatments. But you know, we'll talk about diet, mood, sleep, and exercise a lot as we go on. Post-COVID symptoms. We've heard this. I just came from next door. A lot of post-COVID. Difficulty breathing. All kinds of things. Chronic cough. Headache. Fast-beating heart. POTS. I mean, you know, this postural orthostatic hypertension syndrome. Is that related? Sleep problems. Everything you could imagine under the sun. Stroke. There is some literature about increased risk. Meta-analysis. Anxiety, depression, fatigue, sleep disorder, PTSD, also huge. Because there's been a lot of fear, so why wouldn't it be PTSD? And this diagnosis really comes from frequent rumination about something that happened to So a lot of them are going to fall into this category. Emerging psychiatric symptoms. These are some sort of stigma. Female. Social isolation, etc. We move on a little bit to a person who bends over and hits her head under an administrative desk. Now, any clinician that I know in Occ Med has seen this a lot because, I don't know, in my week, I'm easily seeing 6 to 12 of exactly like this. And they have still symptoms 6 to 18 months later. Why? I ask. I did some telemedicine this morning. Three of them had under-the-desk syndrome. Under something. But this person is also a commercial driver, so for those in the audience who are interested in that sort of thing, you know who you are. Concussion, remember, does not need a contact situation. It's acceleration-deceleration. Mildest form of traumatic brain injury. This is just a term, term concussion. They misdiagnosed me. What do you mean? Oh, they said I just had a head injury. Okay. Well, this is a word we use to describe symptoms after whacking your head. It's not really much more than that. Concussion, MTBI. MTBI, okay, a little bit more severe. Comorbidities contribute to resolution. The hugest thing I'm going to say about this kind of thing. Military and sports. They actually have organized systems. Why not in workers' comp? Why not in other settings? We try. We need to continue working with guidelines and being consistent with how we approach these people. So basically, acceleration-deceleration, and then the idea of amnesia can be helpful. No amnesia? Okay. Maybe a little less intense than others. So when you think about return to work, I mean, this is the most complicated areas, but there are other complicated areas, and generally speaking, you have this mild head injury with loss of consciousness or not. What do I do? They just had a head injury. Can they go back to being a commercial driver? Can they go back to being in a safe position? It's all on you, doc, or provider that you are. It's on you. What do I do? Yeah, a month. Are you back to doing your exercises that you normally did before you had this injury, or did you ever exercise? What do you like compared to the way you were before? Can you jump up and down in my room on both legs? Can you do a squat and a lunge? Are you going to need to? What are you going to need to do? So I kind of really put them through the little FCE in my own office and make them do things. If they can't and they get dizzy or they don't complain, I'm still skeptical because you never know if they're trying too hard. So you've got to use your gut feeling, and this is really what we're told to do. There's an expert panel in 2009. Again, one month no LOC, three months of positive LOC. So now three months after the original head-under-the-desk syndrome, they have multiple symptoms. All the things that you've seen and loved in your clinic, dizziness, insomnia, we're going to keep going here. Concussion, a little less than MTBI. The more symptoms they have on the day of concussion, the more likely that they're not going to get better so quickly or it's going to be longer. Comorbidities are huge, and the list can go on and on, including stuttering, bladder incontinence. Is bladder incontinence related to the head injury that happened under the desk? You better take a look and think about what things you want to do about that and examine them. Do they have a myelopathy that they had before or they never knew, or what is it related to? Post-traumatic headache, you have the idea of migraine versus tension. Again, I talked earlier, migraine, usually unilateral, severe, exercise makes it worse, pulsatile. Post-traumatic, gets better with ice, bilateral, tight squeeze, responds to ibuprofen, but yeah, I guess migraine could too. You're thinking, is this caffeine? Is it medication overuse? That's a huge one. Do they have a 30-year history of back pain and have been given OxyContin and have been taking that and forgot to tell you until the third visit? It happens a lot. Cervicogenic, that could be related to work. Are they still working? Well, then you need to consider restricting their duty. Are they working in the middle of the night? They need to consider restricting that so they get better sleep or get into rhythm. Do they have bruxism? Is there sleep apnea? If they have a morning headache, I'm always thinking of sleep, but that sleep could be sleep apnea. It could also be anxiety. All these things come into play. You need to think about treating it. PTSD for nightmares, counseling, they need a psychiatrist. Not easy to get in a worker's comp. Rumination, PTSD, shift work I mentioned, occipital neurology. All the things on the right side are more severe things that could happen, but you may find the MRI that you get after six months shows Chiari. What do you do? Well, you need an opinion by a neurologist neurosurgeon. There's definitely been cases that I've had that Chiari has been surgically repaired and gotten some benefit. So remember, the neurologic exam can very much uncover things that you'd have nothing to do with what you just started thinking about, like pupils. You'll see on the lower left that they are equal only because of pylocarpine, but on the upper left, this is an idiopathic condition, not from a blown pupil, that the left eye is larger because when a direct light or indirect light, there ain't no change. In consensual response, there is some improvement or some constriction, but basically only pylocarpine will tell. But this is idiopathic. Maybe there's lower reflexes. Maybe there are other things. Usually it's a female. Maybe autonomic issues, but benign. You might find an abnormal MRI or an MRI with some weirdness, hippocampal atrophy. Is that going to happen really from a mild whack under the desk? No, but you've got to think about it. How do you communicate to this person? I didn't have this before I went under the desk and now I have 18 months of headaches or 18 months of stuttering or 18 months of fogginess or brain fog or even COVID could come up with this. What about a 77-year-old with atrophy? How do you communicate to these people that this is maybe not related, but you have to take steps to help yourself and figure out what this could be? Talk to your PCP. A 51-year-old, white matter changes. Very, very common. I get MRIs on people who have head injuries or confusion or issues and they have subtle stuff. So what do you do in the workers' comp setting with subtle stuff? You explain to them that there's many causes for this. This is certainly not related to your trauma under your desk or what have you, but that there may be things that you can do to improve your risks of stroke or other things and that's another long discussion we will have a little bit more of. But when you have a headache, you can't just go to medicine first. You can't. Ice, heat, stretching, yoga, creams, deep breathing. I mean, we've got to start learning how to teach people how to meditate and do breathing exercises. It's more important than anything else we do probably for a lot of people because we're not even going to get the things we want authorized anyway. So you've got to frigging treat these people. Teach them something. Guide them to meditate. Sit for five minutes and do a little meditation. Breathe to 10 with them. I do. But then, yeah, there's biofeedback and other things you can do. Yes, the Academy of Neurology has all kinds of literature. This is a great reference. This is definitely in your handout. I suggest you look at it. You know, aspirin, diclofenac, ibuprofen. Sure, triptans. I'm not a big triptan fan. DHE sprays. There's lots of things for short-acting things. There's also lots of side effects for these kinds of things, right? Ditans, G-Pants, lots of new medications. Some of them work better than others, but they're very expensive. Who's going to be able to get those medicines? What of our populations are we seeing? We're seeing all kinds of different populations. They can't get it. Worker's comp's not going to approve it anyway. Huge list of preventive medicines. There's some better than others. Many have side effects. Amitriptyline, straightforward. Gabapentin, maybe. Make sure you know how to do the dose. Don't just give them a low dose and then forget about them, and then the patient says, I tried it but it didn't work, because that means nothing. If you think that you need a medicine because they have too frequent headaches, and you're not going to go narcotic, you're not going to do too frequent short-acting medicine, give them something that they can use, but know the dose you want to bump it up to, because it didn't do anything. You didn't give it a try unless you know the dose. Know the dose. Look it up on UpToDate. UpToDate is the best reference that I love. And don't forget, you can do things like magnesium, 400 to 600 milligrams once or even 200 BID, and there's literature supporting that this helps reduce frequency, intensity, and duration of headaches of all sorts, migraine or non-migraine. Don't forget melatonin. I'm actually a big fan of like .5 a night, because one month of .5 a night has literature to support reducing headaches. But all these things are things we can learn about. And they're not to be taken lightly, because they're safer, well, many of them are safer than these long-acting medicines, certainly cheaper. Medication overuse headache is a big deal, 10 or 15 times a month is the issue. Managing it, basically you're trying to put them on a preventive medication, you're trying to reduce these short-acting medications, but there's literature about steroids along with the preventive medication. I added this slide today because it's really important. Sure, marijuana could reduce the intensity today of my horrible headache, might also reduce the duration of it, and there's no side effects, yippee, hmm. But it also, there's some literature that it might help in detox. Against opioids, that's the big thing about marijuana, the big industries are pushing that in a big way. However, there's lack of evidence, reduces over time the efficacy associated with medication overuse headache, which means they're not going to get off anything, it's not going to get you anywhere in my opinion, but there's more information that needs to come. When you talk about sleep, complicated issue, obviously a big one that you can treat is sleep apnea. Other than that, there's a lot of meditation and sleep hygiene, we'll talk about getting them a sleep study is not always easy. Post-concussion dizziness, we're going to talk about this for a little bit. BPPV, exertional dizziness, there are characteristics of these which you should know. It can be less than a minute, but they can be recurrent, and they can variably recurrent for months. So BPPV is something that we need to be able to identify, as opposed to scary central stuff. I've got a lot of good slides coming up. Head impulse tests and Dix-Hall Pipe. We'll see if this works. I don't have any audio here. This is from the Academy of Neurology website, which you will not be able to get in your own. I'm sure you'll see who. No volume, but what happened there? It's working here, but not here. Oh my goodness. Working here, not working here. Bummer. What now? Hello? IT people? Hello? Can someone get his attention? Sir, in the back? What? I don't need audio. There's no audio, sir, in this slide. I just said that. It's just video. If you can just go back and start it again. There's no audio. Just turn the slide back on, sir. Forgot his name, but I can. Thank you. Perfect. Well, let me see if I can go back. Just play this again. OK. Here we go again. There is not audio, so don't need to turn audio on. That was unclear. What happened? I'm not sure if that's him or me. There we go. OK. So basically, three things you're doing. Head impulse test, nystagmus, and looking at SKU. Your goal is to find benign things. Looking them straight in the eye. Anybody have familiarity with this? Maybe from listening to other lectures of mine, or I just thought this was a great teaching tool. We all know what nystagmus is, but do we really know? And how to look for it? Cover-on-cover test. So a little bit of catch-up. No direction or vertical nystagmus. Absence of vertical misalignment. We all heard about this Barony maneuver. It's a little bit of a catch-up, but it's a little bit of a catch-up. It's a little bit of a catch-up, but it's a little bit of a catch-up. It's a little bit of a catch-up, but it's a little bit of a catch-up. It's a little bit of a catch-up, but it's a little bit of a catch-up. It's a little bit of a catch-up, but it's a little bit of a catch-up. These are slides you can use in your own clinic. Here's another. So you see her in the upper right. She falls back, and they will start going. We don't have audio to hear that she says she's nauseous, but you see the rotatory nystagmus. I'm going to move on. So visual symptoms are common, debilitating. The acuity may or may not be involved, but certainly important to take a look. And they show all kinds of treatments that start with pencil push-ups and balloons and balls, number five. I literally say, look, you can throw up a balloon and catch it and look. Throw up a balloon, catch it, and look. Then go to balls, which will move faster. Then go to bouncing off the wall. These are things they can do on their own without referring them to vestibular therapists, which you may not find in your community and you may not get. Certainly you don't need an ENT consult for this kind of thing unless things really aren't getting anywhere. But there are corrective lenses in prisons for people who have consensual response problems. But I see lots and lots of these people, and there's a lot of money spent on these people. And you can really help them with things you can do in your own office for a few moments. So then a person may have a seizure. Oh, OK. And how do you determine if it's seizure versus syncope? You think about whether they had tongue biting or incontinence. That's the easy one. You think about amnesia. Did they jerk? And then you want to get a video. Did someone videotape them? Did they get seen? Is it a seizure, syncope, or functional? Hi there. I'm Dr. Rettig, Mike from respiratory. So yeah, there's nothing respiratory, really, that the issue is. But basically, she has these events now for maybe all day, every day, for five months. I've just met her an hour ago now, and nobody has given her an IV by Lantan, bolus, or loaded her up appropriately to see if it's severe seizures or seizures. Had it already for six to eight months, all day, every day, functional, probably, right? But hopefully, someone had done something for her, and her many times to ER. So seizures, you can say tongue biting, incontinence, post-ictal sedation for five minutes or so. Risk of recurrence is significant. It's a provoked seizure, if it is a provoked seizure. Syncope, though, 1% to 3% of all ER visits. Talking about lightheadedness, results from change of posture, pallor, micturition, brief. However, some can actually have seizure activity. Confusing. Syncope, risk of recurrence, most in the first six months. 40% have convulsive syncope. All these other medical conditions are associated with having syncope. If there's cardiac stuff, the risk of recurrence is much higher than without. So when there's no cardiac event, literature says, oh, return them to work. You've got to really be the provider and really make that gut feeling and see what those risks are, if they exist. This is a complicated issue. Certainly, there's a difference between syncope, syncope that is convulsive, syncope with cardiac, seizure, seizure that's unprovoked and late. There's a great chapter by some of our colleagues talking about comorbidities and risk to harm to self and others, recurrence, what do they really do, which helps you make a decision. Post-concussion seizures that happen right after the trauma may have no risk of epilepsy, called the concussive seizure, which is kind of an unusual topic. But then after that, there's an incidence of 0.5% to 10%, depending on the severity of the trauma. Early post, first seven-day seizure increased risk of epilepsy, but if the later ones, even a higher risk. So it's unclear why that's in the literature, because it's even higher if it's late, after that seven days. Medication can help for those with severe head injuries, because it may reduce their risk of having worse or a second seizure, meaning epilepsy and long-term need for these medicines. Obviously, these abnormalities like EEG or MRI increase the risk of epilepsy. So 30-year incidence of post-traumatic epilepsy after TBI is 2% to 16%. Highest risk is in the first six months, but there's a risk for 10 years. At 10 years, risk remains doubled from mild, eight times for severe to have an unprovoked seizure. So this topic is a very complicated one, and certainly DOT and many different organizations have dealt with the literature regarding this. Will my head injury give me dementia? Lots of discussion here. There's a continuum from post-traumatic epilepsy to severe, there's a continuum from one to many to long-term symptoms, et cetera. Or is there a continuum? There's something called traumatic encephalopathy syndrome, which is something we talk about to patients because we can't do brain biopsies. Oh, you have CTE because you have depression. Well, realize that a lot of these symptoms can be similar to simply anxiety and depression after trauma or other kinds of lifestyle problems. And they may not be CTE. You can't make a diagnosis of CTE until it's a brain biopsy. And if you tell them they have TES, they may kill themselves. The literature is really horrible about that. So be careful communicating to people about these kinds of things. Do not make a pre-morbid diagnosis of CTE, not a good thing. We move to tremor. Patients with head injuries often have tremor. Certainly people with carbon monoxide exposures, asphyxiation, welders, solvents, essential tremor, functional tremor are common. Parkinson's tremor and then a Holmes tremor. Now, what I'm doing is doing this. One, two, three, four, five. This is not an easy one to tell what it is. Out loud. One, two, three, four, five. One, two, three, four, five. One, two, three, four, five. Trauma. To the left arm more than the right. What do I do? I have a tremor. Again, one, two, three, four, five. It's a pretty common complaint in my office. One, two, three, four, five. Everybody comes from the primary hot docs, so I suspect you do too. What do you do with these people? This is a person with combined space exposure carbon monoxide. And how old are you, sir? 53 years old. Do you have any family members who've ever had a tremor or Parkinson's or Alzheimer's? No. Any brothers and sisters with Alzheimer's or tremor or Parkinson's? No. Your wife has multiple sclerosis, is that correct? That's correct. OK. How long has she had that? 20 years. Put your left hand also on your lap, too, and uncross your legs if you could. Tell me what happened to you and when this happened. How many months ago did this begin? Three months ago, I was exposed to carbon monoxide poisoning while saw cutting concrete inside a confined space. Had you ever used a respirator before? No. Was the respirator specifically for- We're going to keep moving here. Essential tremor, bilateral, slightly asymmetric, most significant amplitude in the wrist, rather than more proximal or distal. Generally, tremor involves wrist flexion and extension. So, like this, if you're looking at me, rather than Parkinson's, maybe rotation. Flexion and extension, rather than rotation. That's one of the take-homes here. Can I do something wrong? Oh, sorry. Oh, goodness. Can you click on that arrow down there? Yeah. Can you click on that arrow down there? I don't know. What happened here? There we go. Thank you. Again, don't worry about the audio, please. There's no audio. Huh. What happened there? There we go. There we go. Flexion and extension. Unilateral, larger, more than bilateral. Well, bilateral more than unilateral, but can be both. Usually, when they write- You know, Parkinson's has micrographia, so small circles where essential tremor might be wide and large, and these kind of wing-beating things. So this is essential tremor, not Parkinson's tremor. What about this? What are you doing there? I can't control it. Okay. I can't control it. Stand back up now. Look at me. Look at me. Look at me. Open and close your hand. Open and close your hand. No, just look at me and do what I'm doing. Open and close your hand. Open and close the hand. Just the right hand. Open and close as fast as you can. It stops. Focus on the hand. Count to five. One. Two. Three. Four. Now change to the left hand. One. Two. Now let's see- One thing that goes- So Parkinson's, you'll see resting tremor in legs, one-sided, hands, resting in the lap. Usually involves the distal joints. That may not help you, but it's pronation supination. My friend in the back, can you try me there? Hello? Can you click that arrow thing? I don't know why. There we go. Okay. So you've heard of pill-rolling quality, right? Okay. Sometimes they're literally pill-rolling with their fingers. Pronation supination. That's all we've got for you here on that one. Is that the same thing? Or did I just- Is that twice? Looks like it's the same one. I don't know why that would be. So essential tremor- Tremor interferes with motor tasks. So obviously, you know, like anyone else, you ask, is the tremor bothering you? Can you not do things? If they say no, well then, okay, we'll watch it. I'll examine you, and I'll examine you again. But if it interferes with motor tasks, well that's of concern, of interest. Postural or kinetic. Kinetic means finger, nose, finger. Postural, arms out. Flexion extension. The wrist, you know, we talked about this. Flexion extension where this might be Parkinson's, this might be essential, if you're all looking at me up here. Absent at rest. Many other body parts. More than three years of the criteria. Amazingly enough, we all don't know that diet affects us, but yes, there's real literature that meat, certainly cooked meat, has associated with essential tremor. Probably a lot of things. Reduce risk with Mediterranean diet. We'll hear more about that. Worse with caffeine. Improved with alcohol. So literally, essential tremor. Do you ever notice that when you take a beer, sir, that the tremor goes away? You'll find that many say so. Relative, related, absence of other neurological signs. Isolated focal tremor can be in the head and voice. Sir, my clicker ain't not working. Sir, my clicker ain't not working. Oh boy. Sir? In the back? Are you with me? Okay, thank you. I broke it. There we go. Okay. So, types of tremor can be dystonic. Well, obviously dystonia is something you can see. Parkinson's, a Holmes tremor. Fascinating, right? That can be after a stroke or trauma or carbon monoxide, for instance, as the paper that I wrote in that first video you saw, the gentleman with carbon monoxide. Drug-induced tremor, difficult. You got to look and see whether they're on medicines. Neuropathy tremor, that's certainly in the list. Anorexia tremor, we talked about that a bit as well. This is all in your handout. I definitely saw it. It's on that swap card. So, you should have all of this. Parkinson's disease, Bradykinesia tremor and pronation supination tremor, rest, et cetera. We'll keep moving along here. Did I miss something? When you think about functional neurological condition, you want to have a conversation. I think there's something missing. It feels like something is missing here. Maybe not. Functional neurology is a challenging topic because you think, oh, the person may need counseling, et cetera, but you're not really, the goal is really not to communicate that up front. I see that on exam you were distracted when I tested your tremor. My sense is, and your brain MRI is normal, that this is a functional tremor. That means it's a software problem, not a horary problem. There's a lot of people who come to my office with these problems. It's not weird. It's not anything goofy. There are many types of treatments and one of them can be counseling and biofeedback. Oh, I'm a crazy doctor. I know, but let's have this conversation again. It's a software challenge, not a hardware problem. I don't think you have Parkinson's disease. You got to try to be up front. Maybe describe what other things you can find in science, but they also could be functional and real and they could be, it could coexist, so assess these inconsistencies and try to move forward and maybe you need a specialist in these kind of cases. Certainly PT acupuncture and psychology is huge. They may also have depression, anxiety, PTSD, et cetera and patients may very well get angry at you no matter what you try to talk about. Whether there's intention to deceive you is always discussed, certainly in medical legal cases. It's a tough one to prove. Again, out of proportion to the objective findings, that's why I think it's not Parkinson's or not a stroke. One literature, one paper talks about 14% of all these kinds of cases, but that could be 30 or 50 in some kind of clinics would see patients. Hoover's sign is something we've talked about for many years. This is what it is. You can read about it. This is one of my patients that I... I want you to pick this leg entirely off the bed. All the way up high as you can. To the ceiling. To the ceiling. To the ceiling. To the ceiling. To the ceiling. To the ceiling. To the ceiling. This one goes all the way to the ceiling. This leg goes up all the way to the ceiling. Come on. Okay. To the ceiling. Okay, good. And push me up. Push me up here. Okay. Okay, let's try this. Relax. Let's try this again. This leg. This leg. Left leg. I want you to push up against my hand as strong as you can. Strong as you can. Come on. Come on. Strong as you can. Strong as you can. Strong as you can. Okay. So you have a functional condition. It's genuine. It's common. I found these parts of exam. Software, not the hardware. It's not multiple sclerosis because show them what you're thinking. Put it in and document it. With regards to carbon dioxide, you may find anything. You could also find a functional condition. But there have been certainly people with tremor and movement disorder type syndromes. They may or may not have abnormalities in their MRI. There are multiple presentations of carbon dioxide from mild to severe. Those with severe carbon dioxide poisoning may very well have a biphasic presentation such that they get better. And then they come back with a mutism and then incontinence or gait and a Parkinsonism. So these are kinds of unusual cases. Combined space is dangerous as we know. And I recently seen a patient who had a knockdown syndrome found unconscious at a very high level. What was it that caused this? The situation of loss of consciousness and a fall? What's going on? He didn't seem to have any abnormalities for the cardiac. The emergency room ready did not do a carboxyhemoglobin. Don't ask me. It's in the state where everybody comes and not to mention this person is clearly known to be in a construction site at 150 feet above the ground with gases and whatnot. But he was outside. So that's interesting. Actually, I'm confusing you. Let's go back. Talking about two different cases. We're gonna speak about the other case in a moment. This person was based unconscious at work, found sleeping in a basement as a manager of a construction site and found elevated carbon monoxide. Had a tremor. Basically went along for months and years. Unable to work, some confusion, some mild cognitive problems, but also a lot of sleep problems. And then was found to have a whopping MRI with white matter up the yin-yang. Not just from the earlier MRI images that showed one or two ditzels or white matter changes. There's hundreds. And so, you know, we have this MRI. Now, is this a new MRI? Did we have an MRI before he had this exposure? We don't. But this is quite unusual. So we have a lot of the constellation of symptoms and his progress, even though there is a medical history, certainly is in part associated with this significant exposure. Neuroimaging and carbon monoxide can be atrophy of the hippocampus, globus pallidus necrotis, but also hyperintensity of white matters. Where's that threshold of how many white matter ditzels is applicable versus not? That's a discussion that we can all have. Not easy. EEG can reveal some slowing. So Parkinson's disease was discussed in many patients, but now the emerging information is about solvents and PD. There's a lot of literature about solvents. In this patient, we had an administrative worker who worked in a chemical company, and she had 30 years of exposure in a factory. A lot of PPE was supposed to be used, but no one really used it. It was inadequate. She was exposed to MEK and toluene, but also TCA and TCE. TCE was present in the plant up to 30 times the TLV. So this is an invisible cause of Parkinson's now. There's lots of literature emerging from a specific setting in the Southeast where TCE is basically ubiquitous anyway in our entire water supply because it's the most common agent of our Superfund sites. And so we've got to be very careful to look about municipal water because TCE is associated with higher incidences of a lot of neurodegenerative diseases, clearly Parkinson's disease, and it's a contaminant not just from ingestion, but it's also through vapor intrusion. There's all kinds of literature with regards to animals, and there's also hobbies that are connected with larger exposures from inhalation. So this exposure can be occupational as well as environmental. The incident of Parkinson's disease is two times consistent with prior studies of the prevalence of PD in our communities. So Parkinson's is increasing in our communities, linked to pollution, TCE, metals, pesticides. Paraquat has been in the literature a lot, and in the news, there's prodrome of PD identified. That is to say that before you get frank Parkinson's disease there are issues with smell. What about COVID? Putting that aside. Gastrointestinal problems. What about anxiety? Sleep. What about anything? Mood. So there's a new vogue with regards to Parkinson's and neurological prevention to talk about these things, identifying people who should be in preventive studies to assess how they can be slowed or even halted from moving forward from a preclinical setting to a motor setting. And those in the audience who know me know that I'd be interested in the diet, exercise, and mood issue, and it's all starting to come out. But they're not pharmaceutical companies to make a lot of money off these research, so it's not that much. Anyway, we know about Maneb and Paraquat and Rotenone. There's some environmental studies and certain communities who've got increased risks of PD, and they have identified exposures. Paraquat uses herbicide, onset of PD early, but typical symptoms respond to medication. And that's not inconsistent with a lot of other exposures. Manganese, certainly similarly, can be at a high level exposure, such as in minors can have a very atypical Parkinson's disease. This cock walk was described in Chile. But welders can get it, and they might get an early onset of regular PD earlier than, let's say, 62, which is the average age of developing a neurodegenerative disease, maybe earlier than that. So looking at this, there's all kinds of issues where questionnaires and tests looking at earlier age of onset is consistent with people who have exposures that influence maybe their phenotype from the genotype that they may have already had from the genetics. Neurotoxicity exists when there's chronology preceding symptoms, the agent is associated, and not explained by other things. This obviously brings up lots of questions, but this is the goal when you're looking at this. So this is the case I was mentioning before. A gentleman is asphyxiated and smells rotten eggs and becomes unconscious, still not working, depressed, anxious, syngas identified as the agent of concern. What is knockdown gas asphyxiation? What about carbon monoxide outside? Is it carbon monoxide? What could it be? Simple asphyxiants, hypoxia replaces oxygen, methane, nitrogen, argon, helium, propane, carbon dioxide. Outdoor exposures, if a volume of the gas is high enough. Simple, as I mentioned, argon, carbon dioxide, helium. But systemic asphyxiants, such as hydrogen sulfide, we have an esteemed colleague, Dr. Gadadi, who wrote a great chapter that I recently reviewed, and I found that very helpful when I was looking into this case. And so these are impaired oxygen transport, which inhibit oxidative metabolism. Methane, nitrogen, propane, helium, carbon dioxide are simple, there are lots of industries that where the risks are for these kinds of people. Systemic asphyxiants, rotten eggs, sour gas, olfactory paralysis, irritant, wheezing, a lot of stuff related to H2S. It should be a period with carbon monoxide, obviously fires, automobile heaters, odorless. Methylene chloride metabolizes the carbon monoxide and hydrogen cyanide in those industries, metal, gold, and plastics. Lots of fatalities in oil and gas industry from these agents, from the systemic carbon monoxide, H2S, MeCl2, and HCN. Nitrogen, most common simple asphyxiant, nitrogen. And their deaths reported in confined space in this paper looking at from these two papers I mentioned. So in the case that I saw, the syngas has components of nitrogen, carbon monoxide, methane, carbon dioxide. This person had a lot of depression, rumination. MRI was nonspecific, maybe some sensitive things, maybe things that made sense, maybe things that weren't related. Clearly the issue for me was PTSD for this person was disabled. So when you see a person a year after an event like this, how do you assess the last factor here I'm mentioning, motivation in the injured? What about the motivation of the providers? Is that at all important? What about if the person can't really get a provider to give them a kick in the pants to do things, to teach them about maybe sleep, diet, mood, and exercise, which could help them? What if they're really depressed and that is maybe a secondary or tertiary effect of the exposure or the event or it's PTSD? So these are factors we have to consider when we're doing medical legal evaluation, the motivation of the individual, but the motivation that's around the person. Is there any motivating providers to help these people? And our healthcare system is challenged in that regard. So PTSD can come from lots of things, obviously, and really it's an intrusive re-experiencing of the event and avoidance, numbing negative alteration. Neuropsychologists can help us with this, so can psychologists to make this diagnosis, alteration of arousal or reactivity. Risk of substance abuse, depression. Military personnel, very common. Heart disease is associated, so stress can affect heart disease. These are things we know already. And guess what? Mindfulness can help. Yoga can help. Cognitive behavioral therapy. Trans and magnetic stimulation, something that is not talked much about at Worker's Comp, but certainly something for depression when people are refractory to medicines. So we talked about this before. You know, the general assessment of a person with exposure is is the chronology relevant? Is it consistent? Are there objective findings? On exam or diagnostic study, is it sensitive and specific, the test results? At least some of them. Is the exposure significant enough? Is the trauma significant enough? Are there any other explanations? What does literature say? Initially animal, case studies, case series, anything proactive, anything that is really helpful. Is a disability impacting their life? So if they had an event, but they're still able to do things, don't forget, you gotta ask these questions. Are they able to exercise? Did they before? Are they able to engage in social activities, physical activities, maybe sexual activities? These are questions you have to ask if you're looking to do disability evaluations or medical legal evaluations, and whatever side you're doing consulting on, these are the important questions to see whether their events, whether their activities of daily living are dramatically affected. And document them. I mentioned the motivation of the injured, but also the motivation of the providers. We don't talk about that a lot in our healthcare system and how that can affect the outcome of these traumas, exposure or otherwise. I'm doing exceptionally well time-wise, Dr. Myers. Thank you for paying attention. I'm really doing well. I can't believe it. Dr. Myers was critical of my 126 lives as I was too, but she was very helpful. She should know that. Anyway, the concluding topic here is lifestyle medicine. And really, when I take care of all these patients and look at these people from whatever hat I'm wearing to do so, they may have post-concussion syndrome. They may have headaches, dizziness, numbness, fatigue, brain fog, depression. They may have a neuropathy. Is it from the exposure? Is it from the trauma? Is it from their back? There may be an MRI abnormality, an MRI something, a white matter change where the radiologist says could be shearing from the trauma, but it could also be related to metabolic syndrome or hypertension or diabetes or blood sugar. And by the way, as we age, we all have challenges with metabolism. And just because we have a normal fasting glucose doesn't mean that our metabolism is as good as it could be. Where is that balance between doing what we're supposed to do and living our life and enjoying all the beauties of our world, but also being aware of what we can do to improve our longevity. And then you think about trying to educate the injured worker population in what they can do to improve the longevity and reduce their risks for chronic medical problems, including accidents and trauma, because focusing on diet, mood, exercise, and sleep reduces accidents, whether it's an exposure or a trauma. So COVID, the same. If you have pre-morbid problems and you get COVID, you may very well have a higher likelihood of having longer time to get better, or you may have persistent symptoms like what do I do with anosmia? What do I do with a little bit of brain fog? What do I do with exercise stamina problems? Could be neurotoxicity, could be PTSD. So it could be functional neurology where there's a subconscious childhood emotional trauma that now this head injury, carbon monoxide exposure, metal exposure while I'm a welder might very well in some way light up to lead to a functional problem. And then we have neurodegeneration, which again, we have genotype and phenotype. So the neurologists, the literature, the academic neurologists are moving in a little bit of direction. I'm seeing some of my conferences talk about it more and more, where grants are coming about looking at identifying populations to do studies about behavioral modification to see if these items can reduce the risks of going from premorbid to morbid. Primary prevention, secondary prevention, tertiary prevention and there's a lot more. Sleep hygiene, of course, we talk about this with our patients, regular bedtime, cool, dark and quiet, limit devices, avoid caffeine in the PM, later dinner, earlier dinner, earlier dinners. You're just better when you're walking around not necessarily when you're in bed. So, gee, can you really eat dinner three hours before bed? Not easy. But I saw something in New York Times about how the benefits of eating dinner early in the last couple of days. So people are writing about it. Mindfulness, nightly wind down routine. We kind of know what we're supposed to do. Not easy to do it all. We all have responsibilities. So, trazodone, there's some emerging literature about trazodone that that might be not only good for sleep but not addictive. And even some people or there's populations that have been shown to have prevention from progression of neurodegenerative disease. Should we all be taking trazodone at night, a small dose after 65? Maybe. Melatonin for sure, but some of these people, acupuncture, exercise, meditation, all good things. And then there's SSRIs. Improve slow-wave sleep with trazodone. So it's delayed cognitive decline. Return to work. Obviously, there's other things. Autonomic system can be involved. A lot of people have stamina issues. I'm a big fan of sub-threshold exercise. Also, when you have challenges with a lot of stimulation, well, then you gotta encourage that person to set up these type of settings in their home where they're, let's say, watching TV and maybe they're also keyboarding. They gotta set it up themselves. What are they having problems with? So let's say you do those activities in a setting that's a little bit less intense than it would be to give you a symptom. Set up that environment for yourself and practice in it. Set up the exercise environment and practice in it. If you can stand and boil water, identify your heart rate and how long you did it. Let's see if you can stand and boil water for twice as long. Let's see if you can march in place. Let's see if you can go for a walk. How long? Then go walk in a longer setting. Walk up a little hill for short distances. See if you can continue to gradually improve. These are the tools we have to start using because there's no other magic bullet. And there's literature about this. This is a good slide in the Academy of Neurology literature. Talks about traumatic brain injury and this sleep hygiene topic. Another one with regards to subthreshold exercise. Going back to square one, if you overdo it, but encouragement by the provider during each time. Maybe looking at heart rate. Metabolic syndrome, you know, there really is evidence that improving, doing exercise and reducing BMI reduces metabolic syndrome. But 43% of adults greater than 60 have metabolic syndrome. Think about that number, 43%. And there's these kinds of things have higher triglycerides, higher pre-diabetic controls, other risk factors tremendously. Another Academy of Neurology kind of algorithm with regard to neuromuscular medicine. Some direction, reducing weight by 7%, achieving 150 million minutes of aerobic exercise in a week over a one-year period, improved metabolic parameters dramatically, which improved small fiber neuropathy nerve biopsies or skin biopsies that have small fibers in them. In 2030, there's expected to be 8.2 million people with Alzheimer's and 1.2 with Parkinson's. There's no curative therapies, but there's starting to be modifiable risk factors in diet. Adherence to a Mediterranean diet over three years is associated with a lower risk of the pre-morbid PD and PD. Mediterranean diet hypothesized to protect from alpha-synuclein aggregation, early neural generation gut and brain. Adherence to this Mediterranean diet, lower risk of AD and PD. So more and more of this literature is going out. Reduced odds race for PD and pre-PD in the Sweden literature as well as Canadian literature. Dr. Dale Bredesen, anybody heard of him? Maybe. Neurologist, UCSF trained, worked for the Buxte Institute, researcher. Highly skilled person with all kinds of accolades, but now is on his own trying to promote his own pre-code scenario. When a person comes with Alzheimer's or dementia, he's focusing on those risk factors. Multifactorial disease. You're not gonna find one item of treatment by medicine because it's so many different factors involved and it's inflammation, it's diet, it's obesity, it's sleep, it's this and that. Treatment failures, monotherapy, because there's different subtypes. Large presynaptic period. You have it going on for long before there's medicine even thought about given. Criticized due to lack of clinical trials, of course, but he is, and is also the fact that he gets remuneration, but if you connect with this organization, they have a lot of grants and they'll help people. And what did he talk about? Specifics about diet. Stress. Not just generic like most doctors say, go exercise, go eat a good diet. What the hell do I know about a diet? I don't know anything. What do I do with sleep? I don't sleep well, what do I do? But specifics, what about supplements? There's also other things I've never heard of and so there's literature about these things, so I'm doing deeper dives into this. Hormone replacement, oral hygiene. There's another Milan, Italian and USC scientist who's talking about longevity diets, even a bit stricter than Mediterranean diets, but he's saying that this, in fact, is really the ultimate because of many factors. IGF-1, blood pressure, total cholesterol, inflammation, complex carbs, pescetarian and vegetarian diet. A lot of idealists are talking vegetarianism, but three to four times a week, you're allowed to have fish. What do you know about that? Not so much for red meat, though, but generally the idea of Okinawa, Sardinian, and Loma Linda populations, they kind of are in the hunter-gatherer way and that is to say they have feasts. Weekly or in the weekend, they have feasts with lots of fish and maybe some meat, but during the week, they're mostly eating vegetarian diets with a little fish, some cereals, a lot of grains. Prevents frailty, you have to have protein. Legumes, grains, et cetera, and the life expectancy is 10 to 15 years greater than in other populations. But that bottom line is exercise includes cognition and reduces anxiety and stress, gut motility, metabolism. There's a lot of things that help. They're trying to, we need science, obviously, to believe them, maybe to have companies start reading about them so they can change the the work week of their worker or promote longevity of their work population. So only 8%. I saw someone last week that said 9%. I'm not sure where that came from. I'm within five pounds of my ideal weight. I exercise 30 more minutes most days of the week. I eat plant-based whole diet foods with five fruits and vegetables both days. I don't use tobacco. I have two or few alcohol drinks per day. Now Academy of Neurology recently published some papers. The moderate classification for alcohol is 7 to 9 per week. So if you can be under 7 to 9 per week of drinks, then there may not be a risk of stroke. But the purists might say that's even too much. But 7 to 9 is what the latest stroke literature just shows. 7 to 8 hours of sleep most nights. Are you stressed? Are you having to pull to multiple different directions? Skipping meals? Inadequate sleep? Neglected relationships? Overusing technology? A lot of people are. Prevention of stroke and cancer and dementia. Reduce risk when you sleep. For all these things. Managing stress is key. Identifying it. Creating a boundary. It's a tough one. Ask for help. It's a tough one. Having a professional. I think it's the the most dramatic luxury you could do for yourself. Whatever you do. Having a professional or someone to talk to a couple times a week. That's not your family. Keeping it private. Getting feedback. Mindfulness and meditation is magical. It's delightful. Not easy to do. When you do it, you'll clearly feel the benefit. Physical activity is a lot of fun. Some people have more difficulty doing than others because of physical limitations. But finding ways to have joy in a physical sense is really helpful for many settings. This is some literature talking about specifics of diet. Animal protein, you know, is the horror these days. There's a movie called What the Health. If you haven't seen it, it will disgust you and help you move in a different direction with your diet if you are eating a lot of meat and processed foods. Even chicken. Incredible. Avoid processed foods. Stop before you're full. Meals are social, so it's tough, right? It's sort of like the American dream is to own a home, maybe go out to dinner and have fun. How do you do that when all the restaurants are serving things that with sauces you probably shouldn't be eating much? Well, when you don't go out, try to eat as well as you can. Try to be good to yourself. But yeah, you can be critical of yourself too. But these are the things you shouldn't be doing much of. Everybody has their own issues, so you have to kind of get help. Cigarettes, alcohol, drugs, prescription abuse, caffeine overuse. I mean, this for me is emerging information in neurology to help our populations, certainly in occupational neurology. So there really is correlation with cognitive decline and diet. Intermittent fasting is another topic. Should I do it 12 hours, five days and once a month, five days once a quarter? We have to learn more, but there is some emerging literature. This is really helpful for our mitochondria and certainly to clear away synuclein aggregation for dementia. Environmental factors are a challenge. Unfortunately, we don't know anything about microplastics. Hello. What is in our food? We don't know. It's a terrifying idea. And what are our risks, our latent risks to the things we eat? We try to do the best we can. And that, folks, is my whirlwind talk related to the topics that I think about a lot in my professional life. I'm very, very honored to be here today. Thanks so much. I'm available. This is a painting of Mount Tam and Marin when it snowed. I literally went outside and set up an easel, believe it or not. I had to do it. I think it came up pretty well. Anyway, my email is, I think, on a lot of the first slide, maybe. And I have a cell phone. I'm easily available to chat on any tough or fun case. I like it and I'll be glad to chat back. Anyway, so thanks for coming and happy spring in Philadelphia. And we're early, so I have some questions. Time for questions, if you have any. Anybody? You can come to the podium or just come to me. We still have plenty of time. Yeah, thank you for a great lecture. My question is about carbon dioxide exposure. What kind of exposure? Carbon dioxide exposure. Carbon monoxide. Carbon monoxide exposure, excuse me. I know, you know, people who are exposed to carbon monoxide have acute effect, you know. They will die or they will live. But how, you know, can you talk about, you know, the long-term exposure, long-term consequences of carbon monoxide exposure? Because I had some people exposed to carbon monoxide and they came with a lingering symptom, you know, after a while. So how long does the long-term exposure of carbon monoxide last? Tough question. You know, again, do you mean low-level exposure where they didn't really have complaints and didn't really know what it was from? There's patients like that. There's also patients that have exposure and no longer exposure that still have symptoms months and years later. And those people, just like COVID, just like cognitive, just like concussion, often depends on their pre-morbid setup and what they have going on. You can't really make a definitive statement about what's normal, just like with a head injury. Well, what's normal is probably two to six, two to twelve weeks for a person with a mild head injury, but there's probably 15% of people who still have symptoms. Six weeks, three months, six months. So carbon monoxide, you could imagine the same. People that have long, low-level exposures that go over months, didn't know what it was, and finally they found that they had this from some problem that occurred, an alarm that went off. That can be similarly. You know, the exposure ends, but you've had a year of exposure every day or every night. So again, it's difficult. You know, you do the workup that we talked about for the cases that we talked about, including MRI, and get neuropsychologists involved, and you know, then there are people who get a hyperbolic oxygen in some settings if they are identified early. Did that answer your question? Someone? Okay. Sir. Thank you for all of the discussion of tremor. One thing I didn't see was any discussion of tremor of the head and neck, and I'm wondering if you kind of had some words for us on an approach to looking at that, assessing it, observing it, mostly so that I could make an intelligent report to a neurologist. Intelligent what? Report to a neurologist. Right. Yeah, I mean, you know, bobbing, right, left, you know, rotating, neck flexion, extension, rotation, that kind of thing. You want to describe it like that. That's what you mean. You're obviously doing as much as you can of a neurologic exam, which would want to assess posture, kinetic, finger, nose, finger, head turn, see if there's any change, you know, at rest, looking at cogwheel rigidity, they have anything that gets stuck. If you, you know, distract them, I'm patting my chest or my stomach, what happens with the tremor? Usually they might be smooth, but then if you distract them, you might get some subtle cogwheeling, or even the wrist. You do this kind of thing, it seems smooth, but then you have them tap, and then it's a little bit of cogwheeling. So these are things you're assessing. Can they get out of a bed, off a chair, I mean, stand up by themselves? How's their walking? How's their arm swing? Do they turn well? How's their button doing? You know, because people with Parkinson's have trouble with their fine movement, you know. And that tremor at rest, let's see if we can show you, tremor at rest, you know, pill rolling. Well, we talked about this is more of a central, whereas this might be more Parkinsonian, okay. But you're describing this at rest, with posture, or kinetic. So if I have a kinetic tremor, postural tremor, that may not be with kinetic. So you got to describe rest, posture, kinetic, kinetic movement. So those are description of tremor. Neck, you know, does it, is it dystonic? Is there a spasm? Can you find pain? That's a head tremor, or a neck tremor. Dystonic type of tremor, but it could be a leg thing, you know. So you asked about head and neck, I think? Yes. Well, you know, neck tremors, neck tremors are probably more dystonic tremors, you know. Torticollis can come from trauma, but it's also comediopathic. So these are usually when they turn. You can also identify a cord, what happened there, in their cervical spine. So you're palpating, but you're doing things you normally do. Maybe you're not so commonly used to fingernails, finger, or look at this. So tremors with posture, you know, kinetic this, you know, you move, move their hand. Past pointing, you know, usually cerebellar tremors are past pointing. Then you want to check their, maybe check their, their writing, a circle. So as I said earlier, micrography is Parkinson's. See really small circles? Essential tremors are wide and like this, you know. What's their dominant hand? That helpful? Yeah, thank you. Awesome. Yes. Thank you for your presentation. I am Srivani. I'm coming from Washington State. I practice occupational medicine there. So I have two questions. One thing I see in my practice is there are some whiplash injuries to your neck. So do they cause whiplash? Whiplash. Whiplashes. So do they also cause symptoms like concussion, like dizziness? Oh yes. So can whiplash cause dizziness? Dizziness and other concussion symptoms like. Yes. Eye symptoms. Like eye symptoms? Like blurry vision. Yes. Those things. Yeah, you know, anything can cause anything. That's the whole point of the functional neurology section of the discussion and that's the whole, you know, you know as a provider that you have someone who bangs their knee and the next thing you know they've got numbness down their leg. You're like, what? They just bang their knee. How could that be? It is what it is. You got to try to examine it and see if it makes sense or if it persists then you might do testing. You do exams. You're checking the reflex. You're using the the pinprick. You're seeing is it, is it in a nerve distribution? If it's not, you got to document. Non-dermatomal nerve distribution reduces pinprick or sensation. It's common. Again, with the first case we saw, you know, a lot of these people with arm weakness, let's say that they're, I have police officers who wear vests. They come with arm pain and they think they have a neuritis. Someone said they have brachial plexus or they can't get any weakness. No weakness. They have a vague symptom. Even more common, people who are shoulder injuries who have a tear. Loads of numbness. I'm referring to a billion EMGs a year, you know, and they, you can't find anything. It's some irritation, probably the plexus. Maybe it's the lower trunk, but you can't find anything. The median and the ulnars are normal. Radial and sensories are normal. So it's not, so what I talk about is a neuritis, itis. But to answer your question, you have a head injury, you can have a million things. Why would you be stuttering after a head injury when you bump one under the table? It's maybe something that she, the patient is not aware of. Why? There could be some, you know, underlying emotional trauma where that leads to a stuttering. And that trauma is a lot of stress. She's terrified that she won't be able to go back to work. There's a whole story. He may lose his family if he can't go back to work. He may be identified as an illegal immigrant. There's all these craziness and things happen. So yes, eye symptoms, blurred vision. What do you do with it? Ear ringing. What do you do with it? I presented that case of the pulsatile ear ringing, which is kind of a, you know, literally you're feeling beats in your ear, which is probably more common than we think. But if there's also increased intracranial pressure, and it's a female who's 40, who's fat and fertile, so they say, with gallbladder disease or maybe increased ICP, there may need to be a non-industrial referral for something to assess the ICP. You know, unless it's COVID, then it's in the workers' comp arena, maybe. And someone's got to maybe think about what to do. Acetazolamide, how do you handle that, these cases, you know? My second question is about the lifestyle approaches. How successful are you with your patients? With me or my patients? I mean, you try to experiment yourself, so you can show people what you're doing, and tell them that this is hard, but here's how I'm doing it. I wake up and I have one piece of fruit a day. I don't have two. I wake up and I have oatmeal. I don't eat a lot of eggs. I don't eat bacon. I don't eat soda. I try to say me, and I try to say I'm trying to do this too. Everybody's got these dilemmas. As we age, we're gonna be a little bit larger. We're gonna be a little bit more. So how successful? People pay attention. They meditate. If I sit and meditate someone, and literally sit with them looking eye to eye, and I just breathe, count to five or ten, one in, one out, I get to ten with a patient, and they're paying attention, they're participating, it could really work. I would say I have 70% of those kind of people, they do it. They don't want to do it, then that's, they don't do with me, then they're not gonna do it. When they see me the next time you do it, I've been doing it. Younger people are, some are moving in this direction. Some are very close-minded and can't do it. But if you try to just turn that light on, and another thing is like, you know, you don't need to share everything you do with all of your family. You may get a lot of naysayers in your family calling your cousin, your aunt, your uncle. They don't do it, so why, oh you're weird. That's a California thing. It's not. Eating fruits and vegetables and grains is not a California thing. Sure, I'm from California, but I used to be from here. My medical school's in Philadelphia. Thank you. I mean, I think this stuff is very important. I really do. I think we really should have this kind of thing in the state of our routine. I mean, everybody has relatives or family members or friends who get a diagnosis of Alzheimer's or Parkinson's or stroke, and what is the, what does the health care system do for them? Nothing to do for you. You get a stroke, goodbye. Here's your cholesterol medicine. Are you kidding me? Yes, you're, who's first? I forgot. Okay. So what do you do with your one year beyond the head boo-boo but can't ever go back to work? Believe it or not, I've had neurologists call me several times to try and turf the patient to me, and I said, I can be your consultant, but no, I don't want your patient. Yeah, well, ma'am or sir, what do you do with your day? Oh, anybody in your family have any disability or anything like that? Oh, uh-huh. What about your religious persuasion? Would you ever think about volunteering? Oh, okay, well, I go to the church. Oh, great. What do you do with the church? What do you do with the XYZ? I try to encourage them to volunteer and progressively move forward, but I brought up the motivation. What arena are we in? If these people don't want to help themselves, we can't, I mean, yes, it's a sad story that our disability of our government is paying for some people who are unmotivated, who can function, who couldn't do things for our community. We got to try to encourage people to be a part of their community and help each other because that's what we're doing here. So what do I do with them? That's the conversation I have. I try to have a non-aggressive, sometimes I, you know, try to not hear the voice in my head, but I'm trying to open it up because they seem to be fine. Now, I see a lot of corrections officers. How old do they think when they retire? Younger than me. They're 51. You're 50 years old. Come on. What do they do? They have claims in every body part. What do you do? I go fishing or on my ATV. I have lots of property. So you need me to work up your workers comp claims? Really? Whatever population is, it's challenging, but you know, you got to be tender and you're the treater. Well, sometimes you're the evaluator and these are challenging topics. How do you do it? What do you do? So the neurologist, yeah, I mean I get a lot of occ docs say things, oh the head injury, I don't know what to do. You got to go to the neurologist. I mean fortunately they have me around, but most communities don't have a neurologist who's also board of med and so the neurologists are like, don't call me. I'm only going to be, I'm only going to help you with identifying the esoteric tremor or the esoteric neurodegenerative disease that you've never heard of. We don't really want to do that. We're not going to do workers comp. We're not going to do workers comp. I have arguments with my UCSF department. Not only do they not do workers comp, however, I'm making progress. I have insight. I can get them into moving disorder, neuromuscular, you know, the COVID, the PTSD, only if I push and shove with the chairman because I know the chairman well. UC Davis doesn't pay attention. I can't get anyone to an epilepsy center to get an epilepsy monitor if you don't know if it's functional or real from a trauma or blood in the brain. Terrible. But the other thing is, even if they do take you, the wait time for a university level specialist, not something they're transparent yet about. I'm trying to break that down. If I can, at least the UCSF and UC Davis. Great. Thank you very much. Excellent, excellent talk and covered a lot of really relevant topics. I'm Scott Morris, by the way, from Seattle. So what would be your threshold for electrodiagnostic studies? So EMG, NCV, four weeks is what I've sort of learned is enough time to get a valid result. Do you think it's could be shorter or? I mean, you want to get a little PT and a little something going. So I'm kind of in a six week routine. That's kind of where I'm at. But, you know, you know, if you see, you know, dramatic weakness and atrophy, yeah, it's time for an EMG, right? There's no atrophy, then you really want to see if there's well, you're talking about what hand, a limb, a neck. If you've got a reflex loss, you got to get them to get an MRI and get a neurosurgeon involved. If they can, if this can be, you know, assessed and done something with, you got rotator cuffs slash neck things that are crazy. You don't know what it is. But look, if you see atrophy, that's one sided, you get their shirt off, you see a limb issue. It could be too far gone if it's a carpal tunnel. If you see atrophy in the leg and it's a foot drop, foot drop's a tough one. I have lots of people, they come to me with foot drops and they don't have foot drops. They have a heel problem. They've got panorama, panorama fasciitis. They, you know, and then they get encouraged to limp and it's tough. They get an AFO before they even had anything. So I don't like that. Podiatrists will do surgery before there's an EMG for neuropathy, huh? Tarsal tunnel syndrome surgery before the EMG to see if they have diabetic neuropathy. And it's authorized. And then most of the time it isn't authorized. So anyway, six-ish weeks, but atrophy is kind of the thing I like to say about that. Point. Thank you. Well, thanks for hanging out. Thank you.

lecture

Dr. Jonathan Rutchick

neurologist

occupational medicine

chemical exposure

neurodegenerative diseases

neuroimaging

EEG

lifestyle factors

prevention

mindfulness

holistic approach